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It seems like since the Patient Protection & Affordable Care Act (PPACA) premium members was passed in 2010, everyone has been playing the game of "wait and see." Part of that is by design-many of the provisions of the legislation do not go into effect until 2014-and part is due to political opposition to the law itself. First, we saw states waiting until the Supreme Court ruled on the constitutionality of the law (see The Supreme Court Decision Matters And It Doesn'tall members). After the legislation cleared that hurdle, we saw states waiting on the outcome of the Presidential election. And now, with President Obama moving into his second term, all that waiting is about to change.

In light of all the waiting, HHS has held firm to the November 16 declaration deadline, but has decided to give states more time to develop their "Blueprint applications." On November 9, HHS Secretary Kathleen Sebelius announced that states that are planning a state-based exchange (a health insurance exchange in which the state will develop and operate the exchange on their own, without the federal government) will have until December 14 to submit their plan, and states that are planning a partnership exchange (a health insurance exchange in which the state will partner with the federal government) will have until February 15 to submit their plan (see Sebelius Letter To State Governorspremium members).

3 states have established exchanges via executive order: New York, Kentucky, and Rhode Island

3 states have decided to establish partnership exchanges with the federal government: Illinois, Arkansas, and Delaware

10 states have formally declined setting up a state-based exchange, meaning that the federal government will set up an exchange for them: Alaska, Kansas, Louisiana, Maine, Missouri, New Hampshire, Texas, South Carolina, South Dakota, and Virginia.

24 states have yet to decide how to move forward

However states decide to move forward with the creation of health insurance exchanges, one thing we can be sure of now is that they will become a reality - and that by January 1, 2014 each state will have its own insurance exchange up and running.